SAFE LAPAROENDOSCOPIC APPROACH TO BILIARY PANCREATITIS IN OLDER PATIENTS

Objective: To evaluate management strategies for biliary pancreatitis in different age groups. Design: Retrospective review. Setting: Large private metropolitan teaching hospital. Patients: Patients seen betwee n January 1991 and December 1994 with a diagnosis of biliary pancreati tis (N = 136) divided into 2 groups (group 1, aged < 65 years group 2, aged greater than or equal to 65 years). Interventions: Primary treat ments included endoscopic retrograde cholangiography (n = 36) alone or with endoscopic sphincterotomy (n = 27); operative procedures, includ ing cholecystectomy by laparoscopic (n = 54) or open (n = 16) approach es; or no definitive therapy (n = 22). Secondary treatments of common bile duct stones included laparoscopic transcystic bile duct explorati on (n = 5), open common bile duct exploration (n = 4), or postoperativ e endoscopic retrograde cholangiography (n = 10). Main Outcome Measure s: Success of interventions, incidence and treatment of common bile du ct stones, morbidity and mortality rates, frequency of retained stones , and length of hospitalization. Results: Numbers of Ranson criteria w ere higher for older patients (group 1, 0.83 +/- 0.12 vs group 2, 1.57 +/- 0.11 [mean +/- SEM] P < .001). Primary endoscopic retrograde chol angiography with or without endoscopic sphincterotomy was performed ea rlier than operative procedures, with a significantly higher incidence of common bile duct stones (72% vs 19%; P < .001). Number of primary procedures and complication and mortality rates for endoscopic retrogr ade cholangiography with or without endoscopic sphincterotomy were 36, 8%, and 3%, respectively; for laparoscopic cholecystectomy, 54, 9%, a nd 2% respectively: and for open cholecystectomy, 16, 6%, and 19%, res pectively. For complication and mortality rates, there were no statist ical differences between groups or among treatments. Deferred therapy was used in 30 patients, with 20% readmitted for recurrence of biliary pancreatitis. Length of intensive care unit and total hospital stay w ere similar for all groups and treatments. Conclusions: Older patients with biliary- pancreatitis may be safely treated with a combined lapa roendoscopic approach. Management of common bile duct stones depends o n age, with laparoscopic transcystic duct exploration or open common b ile duct exploration preferred for younger patients and laparoscopic t ranscystic duct exploration or postoperative endoscopic sphincterotomy for older ones. Deferred therapy has a substantial relapse rate.